Provider Demographics
NPI:1679740963
Name:MILLIREN, NICOLE (MS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MILLIREN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4458
Mailing Address - Country:US
Mailing Address - Phone:608-386-5495
Mailing Address - Fax:
Practice Address - Street 1:605 4TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4458
Practice Address - Country:US
Practice Address - Phone:608-386-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4036-125101YM0800X, 101YP2500X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100007945Medicaid